Comparison of sleep in osteoarthritic patients and age and sex matched healthy controls

ANGPTL3 deficiency associates with the expansion of regulatory T cells with reduced lipid content

BACKGROUND AND AIMS

Angiopoietin-like 3 (ANGPTL3) regulates lipid and glucose metabolism. Loss-of-function mutations in its gene, leading to ANGPTL3 deficiency, cause in humans the familial combined hypolipidemia type 2 (FHBL2) phenotype, characterized by very low concentrations of circulating lipoproteins and reduced risk of atherosclerotic cardiovascular disease. Whether this condition is accompanied by immune dysfunctions is unknown. Regulatory T cells (Tregs) are CD4 T lymphocytes endowed with immune suppressive and atheroprotective functions and sensitive to metabolic signals. By investigating FHBL2, we explored the hypothesis that Tregs expand in response to extreme hypolipidemia, through a modulation of the Treg-intrinsic lipid metabolism.

METHODS

Treg frequency, phenotype, and intracellular lipid content were assessed ex vivo from FHBL2 subjects and age- and sex-matched controls, through multiparameter flow cytometry. The response of CD4 T cells from healthy controls to marked hypolipidemia was tested in vitro in low-lipid culture conditions.

RESULTS

The ex vivo analysis revealed that FHBL2 subjects showed higher percentages of Tregs with a phenotype undistinguishable from controls and with a lower lipid content, which directly correlated with the concentrations of circulating lipoproteins. In vitro, lipid restriction induced the upregulation of genes of the mevalonate pathway, including those involved in isoprenoid biosynthesis, and concurrently increased the expression of the Treg markers FOXP3 and Helios. The latter event was found to be prenylation-dependent, and likely related to increased IL-2 production and signaling.

CONCLUSIONS

Our study demonstrates that FHBL2 is characterized by high Treg frequencies, a feature which may concur to the reduced atherosclerotic risk in this condition. Mechanistically, hypolipidemia may directly favor Treg expansion, through the induction of the mevalonate pathway and the prenylation of key signaling proteins.

Development of a novel intervention to improve sleep and pain in patients undergoing total knee replacement

Background

Up to 20% of patients experience long-term pain and dissatisfaction after total knee replacement, with a negative impact on their quality of life. New approaches are needed to reduce the proportion of people to go on to experience chronic post-surgical pain. Sleep and pain are bidirectionally linked with poor sleep linked to greater pain. Interventions to improve sleep among people undergoing knee replacement offer a promising avenue. Health beliefs and barriers to engagement were explored using behaviour change theory. This study followed stages 1–4 of the Medical Research Council’s guidance for complex intervention development to develop a novel intervention aimed at improving sleep in pre-operative knee replacement patients.

Methods

Pre-operative focus groups and post-operative telephone interviews were conducted with knee replacement patients. Before surgery, focus groups explored sleep experiences and views about existing sleep interventions (cognitive behavioural therapy for insomnia, exercise, relaxation, mindfulness, sleep hygiene) and barriers to engagement. After surgery, telephone interviews explored any changes in sleep and views about intervention appropriateness. Data were audio-recorded, transcribed, anonymised, and analysed using framework analysis.

Results

Overall, 23 patients took part, 17 patients attended pre-operative focus groups, seven took part in a post-operative telephone interview, and one took part in a focus group and interview. Key sleep issues identified were problems getting to sleep, frequent waking during the night, and problems getting back to sleep after night waking. The main reason for these issues was knee pain and discomfort and a busy mind. Participants felt that the sleep interventions were generally acceptable with no general preference for one intervention over the others. Views of delivery mode varied in relation to digital move and group or one-to-one approaches.

Conclusion

Existing sleep interventions were found to be acceptable to knee replacement patients. Key barriers to engagement related to participants’ health beliefs. Addressing beliefs about the relationship between sleep and pain and enhancing understanding of the bidirectional/cyclical relationship could benefit engagement and motivation. Individuals may also require support to break the fear and avoidance cycle of pain and coping. A future intervention should ensure that patients’ preferences for sleep interventions and delivery mode can be accommodated in a real-world context.

Associations of Actigraphic Sleep Parameters With Fatigability in Older Adults

BACKGROUND

Poor sleep may increase the likelihood of fatigue, and both are common in later life. However, prior studies of the sleep-fatigue relationship used subjective measures or were conducted in clinical populations; thus, the nature of this association in healthier community-dwelling older adults remains unclear. We studied the association of actigraphic sleep parameters with perceived fatigability-fatigue in response to a standardized task-and with conventional fatigue symptoms of low energy or tiredness.

METHODS

We studied 382 cognitively normal participants in the Baltimore Longitudinal Study of Aging (aged 73.1 ± 10.3 years, 53.1% women) who completed 6.7 ± 0.9 days of wrist actigraphy and a perceived fatigability assessment, including rating of perceived exertion (RPE) after a 5-minute treadmill walk or the Pittsburgh Fatigability Scale (PFS). Participants also reported non-standardized symptoms of fatigue.

RESULTS

After adjustment for age, sex, race, height, weight, comorbidity index, and depressive symptoms, shorter total sleep time (TST; <6.3 hours vs intermediate TST ≥6.3 to 7.2 hours) was associated with high RPE fatigability (odds ratio [OR] = 2.56, 95% confidence interval [CI] = 1.29, 5.06, p = .007), high PFS physical (OR = 1.88, 95% CI = 1.04, 3.38, p = .035), and high mental fatigability (OR = 2.15, 95% CI = 1.02, 4.50, p = .044), whereas longer TST was also associated with high mental fatigability (OR = 2.19, 95% CI = 1.02, 4.71, p = .043). Additionally, longer wake bout length was associated with high RPE fatigability (OR = 1.53, 95% CI = 1.14, 2.07, p = .005), and greater wake after sleep onset was associated with high mental fatigability (OR = 1.14, 95% CI = 1.01, 1.28, p = .036).

CONCLUSION

Among well-functioning older adults, abnormal sleep duration and sleep fragmentation are associated with greater perceived fatigability.

Evaluating the efficacy of Internet-Based Exercise programme Aimed at Treating knee Osteoarthritis (iBEAT-OA) in the community: a study protocol for a randomised controlled trial

INTRODUCTION

Knee osteoarthritis (OA) is the most common joint disease worldwide. As of today, there are no disease-modifying drugs, but there is evidence that muscle strengthening exercises can substantially reduce pain and improve function in this disorder, and one very well tested physiotherapy protocol is the 'Better Management of Patients with Osteoarthritis' developed in Sweden. Given the high prevalence of knee OA, a potentially cost-effective, digitally delivered approach to treat knee OA should be trialled. This study aims to explore the benefits of iBEAT-OA (Internet-Based Exercise programme Aimed at Treating knee Osteoarthritis) in modulating pain, function and other health-related outcomes in individuals with knee OA.

METHODS AND ANALYSIS

A randomised controlled trial was designed to evaluate the efficacy of a web-based exercise programme in a population with knee OA compared with standard community care provided by general practitioners (GPs) in the UK. We anticipate recruiting participants into equal groups. The intervention group (n=67) will exercise for 20-30 min daily for six consecutive weeks, whereas the control group (n=67) will follow GP-recommended routine care. The participants will be assessed using a Numerical Rating Scale, the Western Ontario and McMaster Universities Osteoarthritis Index, the Arthritis Research UK Musculoskeletal Health Questionnaire, the Pittsburgh Sleep Quality Index, 30 s sit to stand test, timed up and go test, quantitative sensory testing, musculoskeletal ultrasound scan, muscle thickness assessment of the vastus lateralis, and quadriceps muscles force generation during an isokinetic maximum voluntary contraction (MVC). Samples of urine, blood, faeces and synovial fluid will be collected to establish biomarkers associated with changes in pain and sleep patterns in individuals affected with knee OA. Standard parametric regression methods will be used for statistical analysis.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Research Ethics Committee (ref: 18/EM/0154) and the Health Research Authority (protocol no: 18021). The study was registered in June 2018. The results of the trial will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03545048.

Influence of Obstructive Sleep Apnea in the Functional Aspects of Patients With Osteoarthritis

STUDY OBJECTIVES

It has been demonstrated in recent studies that obstructive sleep apnea (OSA) is the most prevalent sleep disorder in patients with osteoarthritis (OA), and thus the current study aimed to investigate the influence of OSA on knee extensor torque, pain, stiffness, and physical function in men with low-grade knee OA.

METHODS

The study included 60 male volunteers, aged 40 to 70 years, allocated into four groups: Group 1 (G1) Control (n = 15): without OA and without OSA; Group 2 (G2) (n = 15): with OA and without OSA; Group 3 (G3) (n = 15): without OA and with OSA; and Group 4 (G4) (n = 15) with OA and with OSA. All volunteers were examined using knee radiographs and polysomnography, responded to the Western Ontario McMaster Osteoarthritis Index (WOMAC) questionnaire, and completed a test on an isokinetic dynamometer to evaluate peak isometric knee extensor torque, both concentric and eccentric (90°/s and 180°/s).

RESULTS

Regarding the data from the WOMAC questionnaire (for pain, stiffness, and physical function), it was observed that G4 showed higher values compared to G1 or G3. For the concentric isometric and isokinetic peak knee extensor torque, lower values were observed in G4 compared to G1 or G3.

CONCLUSIONS

Patients who have knee OA in the early grades, when associated with OSA, have higher changes of the peak extensor torque, pain, stiffness, and physical function, compared with patients who did not have OSA.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov, Identifier: NCT01422967, Title: Changes Of Sleep on the Sensoriomotor and Cytokine In Patients With Osteoarthritis, URL: https://clinicaltrials.gov/ct2/show/NCT01422967.

Spontaneous painful disease in companion animals can facilitate the development of chronic pain therapies for humans

OBJECTIVE

To outline the role that spontaneous osteoarthritis (OA) in companion animals can play in translational research and therapeutic pharmacological development.

OUTLINE

Narrative review summarizing the opportunities and limitations of naturally occurring, spontaneous OA as models of human OA pain, with a focus on companion animal pets. The background leading to considering inserting spontaneous disease models in the translational paradigm is provided. The utility of this model is discussed in terms of outcome measures that have been validated as being related to pain, and in terms of the potential for target discovery is outlined. The limitations to using companion animal pets as models of human disease are discussed.

CONCLUSIONS

Although many steps along the translational drug development pathway have been identified as needing improvement, spontaneous painful OA in companion animals offers translational potential. Such 'models' may better reflect the complex genetic, environmental, temporal and physiological influences present in humans and current data suggests the predictive validity of the models are good. The opportunity for target discovery exists but is, as yet, unproven.

Polysomnographic characteristics in nonmalignant chronic pain populations: A review of controlled studies

Sleep and pain are critical homeostatic systems that interact in a bidirectional manner. Complaints of sleep disturbance are ubiquitous among patients with chronic pain disorders, and conversely, patients with persistent insomnia symptoms commonly report suffering from chronic pain. Sleep deprivation paradigms demonstrate that partial or complete sleep loss induce hyperalgesia, possibly due to shared mechanistic pathways including neuroanatomic and molecular substrates. Further, chronic pain conditions and sleep disturbances are intertwined through comorbidities, which together cause detrimental psychological and physical consequences. This critical review examines 29 polysomnography studies to evaluate whether nonmalignant chronic pain patients, as compared to controls, show differences in objective measures of sleep continuity and sleep architecture. Whereas these controlled studies did not reveal a consistent pattern of objective sleep disturbances, alterations of sleep continuity were commonly reported. Alterations of sleep architecture such as increases in light sleep or decreases in slow-wave sleep were less commonly reported and findings were mixed and also inconsistent. Methodological flaws were identified, which complicated interpretation and limited conclusions; hence, recommendations for future research are suggested. Knowledge of abnormalities in the sleep process has implications for understanding the pathophysiology of chronic pain conditions, which might also direct the development of novel intervention strategies.

Disrupted sleep is associated with altered pain processing by sex and ethnicity in knee osteoarthritis

Studies indicate that improving sleep decreases reported pain in patients with knee osteoarthritis, but it is unclear if this association extends to experimentally induced pain responses. A community-based sample of 88 African American and 52 non-Hispanic white adults (45-76 years) with knee osteoarthritis completed the Insomnia Severity Index and the arousal subscale of the Sleep Hygiene and Practices Scale. Participants underwent quantitative sensory testing, including measures of pain sensitivity and facilitation at the knee, and pain inhibition. Outcomes were analyzed with multiple Tobit hierarchical regression models, with adjustment for relevant covariates. Ethnicity and sex by sleep interactions were also entered into the models. After covariate adjustment, main associations were not observed. However, sex interacted with insomnia severity to predict greater temporal summation of heat and punctate pressure pain among women and lower heat temporal summation among men. Men and women who engaged in frequent arousal-associated sleep behaviors demonstrated higher and lower heat temporal summation, respectively. Non-Hispanic whites with greater insomnia severity displayed lower pressure pain thresholds and pain inhibition. Our findings are the first to demonstrate that disrupted sleep is associated with altered pain processing differentially by sex and ethnicity/race among people with knee osteoarthritis.

PERSPECTIVE

This article presents the association between insomnia severity, maladaptive sleep behaviors, and experimentally induced pain responses among people with knee osteoarthritis. Disrupted sleep was associated with altered pain processing by sex and ethnicity/race. Offering sleep interventions may help ameliorate pain, but treatment may need to be tailored by sex and ethnicity/race.

Sleep Disturbances and Osteoarthritis

Sleep disturbances are particularly troublesome in patients with painful rheumatic disease. This article reviews the literature specifically published on sleep disturbances in osteoarthritis, a prevalent pathology and leading cause of disability. Several aspects of the relationship between sleep and osteoarthritis are discussed, including epidemiology, pathophysiological hypotheses, and treatment outcomes. Sleep is of central importance in the well-being of patients and should systematically be assessed in patients with osteoarthritis. When needed, a specific treatment of sleep disorders should be associated with an optimal management of pain to achieve synergistic improvements in quality of life. More large-scale studies are needed to identify predictive factors of sleep impairment in osteoarthritis.

Role of sleep in the regulation of the immune system and the pituitary hormones

Sleep is characterized by a reduced response to external stimuli and a particular form of electroencephalographic (EEG) activity. Sleep is divided into two stages: REM sleep, characterized by muscle atonia, rapid eye movements, and EEG activity similar to wakefulness, and non-REM sleep, characterized by slow EEG activity. Around 80% of total sleep time is non-REM. Although it has been intensely studied for decades, the function (or functions) of sleep remains elusive. Sleep is a highly regulated state; some brain regions and several hormones and cytokines participate in sleep regulation. This mini-review focuses on how pituitary hormones and cytokines regulate or affect sleep and how sleep modifies the plasma concentration of hormones as well as cytokines. Also, we review the effects of hypophysectomy and some autoimmune diseases on sleep pattern. Finally, we propose that one of the functions of sleep is to maintain the integrity of the neuro-immune-endocrine system.

Hip pain while using lower extremity joints and sleep disturbances in elderly white women: results from a cross-sectional analysis

OBJECTIVE

To evaluate sleep quality in women with hip pain due to daily activities involving the lower extremity joints.

METHODS

We evaluated the association of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) hip pain severity score with objective sleep measures obtained by wrist actigraphy in 2,225 white women ≥ 65 years of age enrolled in the Study of Osteoporotic Fractures.

RESULTS

Women had an increased odds of spending ≥ 90 minutes awake after sleep onset (odds ratio [OR] 1.28, 95% confidence interval [95% CI] 1.11-1.50) for every 5-point increase in hip pain score after adjustment for all covariates. Hip pain when sitting or lying was the strongest predictor of sleep fragmentation (OR 2.0, 95% CI 1.47-2.73); however, standing pain was associated with a higher number of awake minutes in bed scored from sleep onset to the end of the last sleep episode, independent of pain while in bed (OR 1.41, 95% CI 1.07-2.01). Sleep disturbances increased significantly after the first 2 hours of sleep in women with severe hip pain compared to those without hip pain (mean ± SD 1.4 ± 0.47 minutes per hour of sleep; P < 0.003). Similar associations were observed for long wake episodes >5 minutes. There were no associations between daytime napping, sleep latency, sleep efficiency, and total sleep minutes and WOMAC hip pain.

CONCLUSION

Fragmented sleep was greater in women with hip pain compared to those without hip pain; however, fragmented sleep in women with severe hip pain compared to those without hip pain was unchanged until after the first 2 hours of sleep. Further investigations into pain medications wearing off over time or the prolonged periods of inactivity decreasing the pain threshold are warranted.

Sleep and fatigue and the relationship to pain, disease activity and quality of life in juvenile idiopathic arthritis and juvenile dermatomyositis

OBJECTIVES

To determine and compare the prevalence of disturbed sleep in JIA and JDM and the relationship of sleep disturbance to pain, function, disease activity and medications.

METHODS

One hundred fifty-five patients (115 JIA, 40 JDM) were randomly sampled and were mailed questionnaires. Sleep disturbance was assessed by the sleep self-report (SSR) and the children's sleep habits questionnaire (CSHQ). Fatigue, pain and function were assessed by the paediatric quality of life inventory (PedsQL) and disease activity by visual analogue scales (VASs). Joint counts were self-reported.

RESULTS

Eighty-one per cent responded, of whom 44% reported disturbed sleep (CSHQ > 41); there were no differences between disease groups. Poor reported sleep (SSR) was highly correlated with PedsQL fatigue (r = 0.56, P < 0.0001). Fatigue was highly negatively correlated with quality of life (r = -0.77, P < 0.0001). The worst pain intensity in the last week was correlated to sleep disturbance (r = 0.32, P = 0.0005). Fatigue was associated with prednisone and DMARD use.

CONCLUSIONS

Sleep disturbance and fatigue are prevalent among children with different rheumatic diseases. Sleep disturbance and fatigue are strongly associated with increased pain and decreased quality of life. Strategies aimed at improving sleep and reducing fatigue should be studied as possible ways of improving quality of life for children with rheumatic illness.

Sleep disturbances in adults with arthritis: prevalence, mediators, and subgroups at greatest risk. Data from the 2007 National Health Interview Survey

OBJECTIVE

To examine the prevalence of sleep disturbances in adults with arthritis in a nationally representative sample, mediators of sleep difficulties, and subgroups of individuals with arthritis at greatest risk.

METHODS

Using data on US adults ages≥18 years participating in the 2007 National Health Interview Survey, we computed the prevalence of 3 measures of sleep disturbance (insomnia, excessive daytime sleepiness, and sleep duration<6 hours) among persons with arthritis. We used logistic regression analysis to examine if the association of arthritis and sleep disturbances was independent of sociodemographic characteristics and comorbidities, and to identify potential mediators. We used classification trees to identify subgroups at higher risk.

RESULTS

The adjusted prevalence of insomnia was higher among adults with arthritis than those without arthritis (23.1% versus 16.4%; P<0.0001), but was similar to those with other chronic diseases. Adults with arthritis were more likely than those without arthritis to report insomnia (unadjusted odds ratio 2.92, 95% confidence interval 2.68-3.17), but adjustment for sociodemographic characteristics and comorbidities attenuated this association. Joint pain and limitation due to pain mediated the association between arthritis and insomnia. Among adults with arthritis, those with depression and anxiety were at highest risk for sleep disturbance. Results for excessive daytime sleepiness and sleep duration<6 hours were similar.

CONCLUSION

Sleep disturbance affects up to 10.2 million US adults with arthritis, and is mediated by joint pain and limitation due to pain. Among individuals with arthritis, those with depression and anxiety are at greatest risk.

The multidimensionality of sleep quality and its relationship to fatigue in older adults with painful osteoarthritis

OBJECTIVE

To evaluate subjective sleep quality and its relationship to fatigue in older adults with osteoarthritis (OA).

METHOD

In a community cohort with hip/knee OA, subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and fatigue was measured by the Profile of Mood States - Fatigue subscale (POMS-F). Correlates of sleep quality and fatigue were determined by standardized interviews including socio-demographics, OA severity (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) summary score), comorbidity, depression (Center for Epidemiologic Studies Depression Scale, CES-D), stressful life events, daytime napping, symptoms of restless legs syndrome (RLS) and prior sleep disorder diagnoses. Logistic regression examined correlates of poor sleep (PSQI score>5). Linear regression evaluated the relationship between poor sleep and fatigue, and the effect of napping on this relationship.

RESULTS

In 613 respondents, mean age was 78 years, 78% were female, 11% had concomitant fibromyalgia, and 26% had 3+ comorbid conditions. Responses indicated moderate OA severity. Seventy percent reported poor sleep; 25% met criteria for RLS and 6.5% reported a diagnosed sleep disorder. Independent correlates of poor sleep were: greater arthritis severity (adjusted odds ratio (OR) per unit increase in WOMAC score=1.03, P<0.0001), 3+ comorbid conditions (adjusted OR=1.88; P=0.03), depressed mood (adjusted OR per unit increase in CES-D score=1.09, P<0.0001), and RLS (adjusted OR=1.87; P=0.02). Controlling for previously reported fatigue correlates, poor sleep was significantly associated with greater fatigue (parameter estimate=1.63, P=0.0003) and napping did not moderate this relationship (P=0.55 for the interaction between napping and poor sleep).

CONCLUSIONS

Among older people with OA, poor sleep is highly prevalent and significantly linked with fatigue. Identifying the nature of sleep disturbances in OA is important as treatment of sleep disturbances may reduce OA-related fatigue.

Mechanisms by which sleep disturbance contributes to osteoarthritis pain: a conceptual model

Sleep disturbance is prevalent in aging and painful rheumatologic populations, but it has largely been a neglected dimension of the routine clinical care of arthritis patients. Pain associated with osteoarthritis (OA) is a leading cause of disability worldwide, and factors that contribute to pain in OA are poorly understood. Sleep disturbance is not only a consequence of pain, it is also likely to play an integral role in pain expression. Emerging research suggests that many patients with OA demonstrate signs of generalized hyperalgesia and faulty central pain modulatory processing similar to other idiopathic pain disorders, such as fibromyalgia. Sleep disruption is increasingly recognized as a direct contributor to both hyperalgesia and impaired endogenous pain modulation. This article reviews the extant literature on sleep disturbance and hyperalgesia in patients with OA. We propose a conceptual working model describing pathways by which sleep disturbance interacts directly with central pain processing mechanisms and inflammatory processes, and indirectly with mood and physical functioning to augment clinical OA pain. The clinical and research implications of the model are discussed.

Experiencing painful osteoarthritis: what have we learned from listening?

PURPOSE OF REVIEW

Despite the central role of pain in osteoarthritis, until recently, relatively little attention was paid to the osteoarthritis pain experience, including the features of osteoarthritis pain that are most important to people living with this disease. The focus of this review is on recent advances in our understanding of the experience of osteoarthritis pain from the patient's perspective.

RECENT FINDINGS

To gain an understanding of the experience of pain in osteoarthritis, researchers have largely relied on qualitative methodologies. This research indicates that the osteoarthritis pain experience is multidimensional, reflecting the influence of biological (e.g. pain mechanisms), psychological (e.g. mood and coping), and social factors (e.g. social support). Qualitative and quantitative research to date supports the need for measures that distinguish aspects of the pain itself (intensity, frequency, quality, location, etc.) from the consequences of the pain on activity limitations and participation restriction, mood, sleep, and health-related quality of life. This research has underscored the limitations of existing generic and osteoarthritis-specific pain measures, and is driving the development of new tools to better evaluate osteoarthritis-related pain, and thus assessment of its impact and response to various interventions.

SUMMARY

Improved measurement of painful osteoarthritis, including attention to the words people with osteoarthritis use to describe their pain, will undoubtedly lead to an improved understanding of pain mechanisms in osteoarthritis and, in turn, mechanism-based and evidence-based treatment decision making.

Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis

STUDY OBJECTIVES

Osteoarthritis pain affects more than half of all older adults, many of whom experience co-morbid sleep disturbance. Pain initiates and exacerbates sleep disturbance, whereas disturbed sleep maintains and exacerbates pain, which implies that improving the sleep of patients with osteoarthritis may also reduce their pain. We examined this possibility in a secondary analysis of a previously published randomized controlled trial of cognitive behavioral therapy for insomnia (CBT-I) in patients with osteoarthritis and co-morbid insomnia.

METHODS

Twenty-three patients (mean age 69.2 years) were randomly assigned to CBT-I and 28 patients (mean age 66.5 years) to an attention control. Neither directly addressed pain management. Twelve subjects crossed over to CBT-I after control treatment. Sleep and pain were assessed by self-report at baseline, after treatment, and (for CBT-I only) at 1-year follow-up.

RESULTS

CBT-I subjects reported significantly improved sleep and significantly reduced pain after treatment. Control subjects reported no significant improvements. One-year follow-up found maintenance of improved sleep and reduced pain for both the CBT-I group alone and among subjects who crossed over from control to CBT-I.

CONCLUSIONS

CBT-I but not an attention control, without directly addressing pain control, improved both immediate and long-term self-reported sleep and pain in older patients with osteoarthritis and comorbid insomnia. These results are unique in suggesting the long-term durability of CBT-I effects for co-morbid insomnia. They also indicate that improving sleep, per se, in patients with osteoarthritis may result in decreased pain. Techniques to improve sleep may be useful additions to pain management programs in osteoarthritis, and possibly other chronic pain conditions as well.

Diclofenac potassium restores objective and subjective measures of sleep quality in women with primary dysmenorrhea

STUDY OBJECTIVES

Primary dysmenorrhea is a common gynecological disorder that disrupts daytime functioning and nighttime sleep quality. We determined the effectiveness of diclofenac potassium, compared to placebo, in alleviating nighttime pain and restoring sleep architecture in women with primary dysmenorrhea.

DESIGN

Randomized, double-blind, crossover study.

SETTING

Sleep laboratory.

PARTICIPANTS

Ten healthy women (21 +/- 1 years) with a history of primary dysmenorrhea.

INTERVENTIONS

Placebo or diclofenac potassium (150 mg per day) for menstrual pain.

MEASUREMENTS AND RESULTS

We assessed objective measures of sleep (polysomnography) and subjective measures of sleep quality, mood, and intensity of menstrual pain. Compared to a pain-free phase of the menstrual cycle (mid-follicular), women receiving placebo for their menstrual pain had a poorer mood (P < 0.01), decreased sleep efficiency (P < 0.05), less REM sleep (P < 0.05), more stage 1 sleep (P < 0.01), and more sleep stage changes per hour of sleep during the night. Administration of diclofenac potassium compared to placebo not only attenuated the women's menstrual pain (P < 0.05), but also increased sleep efficiency (P < 0.05) and percentage of REM sleep (P < 0.01), decreased percentage of stage 1 sleep (P < 0.05) and number of sleep stage changes per hour of sleep (P < 0.05), and improved subjective ratings of sleep quality and morning vigilance (P < 0.05).

CONCLUSION

Diclofenac potassium effectively attenuates nighttime dysmenorrheic pain and restores subjective and objective measures of sleep quality to values recorded in a pain-free phase of the menstrual cycle.

A Feasibility Study of Valerian Extract for Sleep Disturbance in Person With Arthritis

Objectives: To present a pilot study of valerian to explore issues of feasibility and efficacy in studies of sedative herbs for arthritis-related sleep disturbance. Methods: Fifteen persons with arthritis and mild sleep disturbance were randomized to receive 600 mg valerian ( Valeriana officinalis, n = 7) or placebo ( n = 8) for five nights.

Results: Protocol adherence (dosing and data collection) was high. Allocation concealment was successful using a novel approach for matching the placebo on the distinctive odor of valerian. Nonsignificant differences between the groups were found on all sleep outcomes, measured by daily diaries and wrist actigraphy.

Conclusion: The study methods were feasible, except for recruitment issues (addressed in the discussion), and may guide the testing of other sedative herbs for persons with arthritis. Although efficacy outcomes were inconclusive due to the small sample size of this study, recent evidence from larger trials of valerian also does not support its efficacy.

Sleep as a marker in the effective management of chronic osteoarthritis pain with opioid analgesics

OBJECTIVES

Sleep disturbances frequently accompany chronic pain from osteoarthritis (OA), and their effective management may reflect successful treatment of chronic pain. The objective of this article is to provide a rationale for using improvement in sleep as a marker for effective management of chronic OA pain with opioid analgesics. For this purpose, available evidence evaluating the relationship between successful management of chronic pain with opioids and improvements in sleep in patients with OA is reviewed.

METHODS

We conducted a comprehensive PubMed search to identify studies that systematically measured the impact of opioid treatment on pain and sleep parameters in the context of chronic pain from OA. Our search criteria included publication in a recognized peer-reviewed journal, randomized placebo-controlled design, and assessment of both pain intensity and sleep as outcomes.

RESULTS

In each of the 10 placebo-controlled studies identified, concurrent improvements in pain intensity and measured sleep disturbances were observed in patients receiving the long-acting opioid analgesics under study. Improved overall sleep quality, reduced awakenings from pain, and increased duration of sleep were among the favorable changes observed in patients with OA treated with long-acting opioids.

CONCLUSIONS

Current evidence suggests that various long-acting opioid analgesics simultaneously achieve pain control and improve sleep. However, the complex interaction between reduced pain and improved sleep requires further study.

Sleep and rheumatologic disorders

Arthritis is the leading cause of chronic illness in the United States. Seventy-two percent of the adults aged 55 years and older with arthritis report sleep difficulties. This review discusses sleep disorders associated with rheumatoid arthritis, juvenile rheumatoid arthritis, Sjogren's syndrome, systemic lupus erythematosus, scleroderma, Behcet's disease, seronegative spondyloarthropathies, osteoarthritis, sarcoidosis, and fibromyalgia. We describe the inter-relationship between sleep complaints, disease activity, depression, sleep deprivation, and cytokines. An algorithm for evaluation and treatment of sleep disorders associated with rheumatologic diseases is proposed.

Osteoarthritis and sleep: the Johnston County Osteoarthritis Project

OBJECTIVE

Little is known about the association of symptomatic osteoarthritis (OA) with sleep disturbance. We compared the prevalence and severity of current sleep problems among individuals with and without symptomatic hip or knee OA in a large, community-based sample.

METHODS

Participants (N = 2682, 28% with symptomatic hip or knee OA) were from the Johnston County Osteoarthritis Project. Six sleep variables were grouped into 2 categories: insomnia (trouble falling asleep, trouble staying asleep, or waking early) and insufficient sleep (daytime sleepiness, not enough sleep, or not feeling rested). The presence of any sleep problem (insomnia or insufficient sleep) was also assessed, as were annual frequency and cumulative days of sleep problems. Adjusted models examined associations of symptomatic OA with sleep problems controlling for demographic characteristics, obesity, self-reported health, and depressive symptoms.

RESULTS

Symptomatic hip or knee OA was associated with increased odds of any sleep problem (odds ratio 1.25, 95% confidence interval 1.02-1.54), insomnia (OR 1.29, 95% CI 1.07-1.56), and insufficient sleep (OR 1.35, 95% CI 1.12-1.62) in adjusted models. Among participants with sleep problems, those with symptomatic OA reported higher median numbers of annual and cumulative days of insomnia and insufficient sleep, although these associations were not statistically significant in adjusted models.

CONCLUSION

Symptomatic hip and knee OA are significantly associated with sleep problems, independent of other factors related to sleep difficulties, including self-rated health and depression. Patients with OA should be regularly screened for sleep disturbance as part of routine care.

The effect of chronic disorders on sleep in the elderly

Sleep disorders are increasingly common as people age. Along with the numerous physiologic changes that occur with aging, sleep patterns are also altered. Inability to get to sleep, shorter sleep times, and changes in the normal circadian patterns can have an impact on an individual's overall well being. In addition, many common chronic conditions, such as chronic obstructive pulmonary disease, diabetes, dementia, chronic pain, and cancer, that are more common in the elderly, can also have significant effects on sleep and increase the prevalence of insomnia as compared with the general population. This is a result not only of the chronic medical illnesses themselves, but of the psychologic and social factors associated with the disease processes.

Quality of life in chronic musculoskeletal pain

This chapter reviews the impact of chronic musculoskeletal pain on patients' health-related quality of life. In addition to the physical health consequences, chronic musculoskeletal pain can have a profound negative impact on an individual's emotional and social well-being. Although efforts in the health sector are obviously of crucial importance in the management of chronic musculoskeletal pain, a high level of patient and societal involvement is key to reducing the burden of this condition. Patients should work in partnership with health-care professionals, actively participating in their care. Family members should encourage their loved ones to be as independent as possible. The employer of a person with chronic musculoskeletal pain has a vital role in returning him or her to work as soon as possible. Removing all barriers to the use of preventive and therapeutic services will help us to reduce the burden of musculoskeletal pain conditions on both patients and society.

Tramadol extended-release in the management of chronic pain

Chronic, noncancer pain such as that associated with osteoarthritis of the hip and knee is typically managed according to American College of Rheumatology guidelines. Patients unresponsive to first-line treatment with acetaminophen receive nonsteroidal antiinflammatory drugs (NSAIDs), including cyclooxygenase-2 (COX-2) inhibitors. However, many patients may have chronic pain that is refractory to these agents, or they may be at risk for the gastrointestinal, renal, and cardiovascular complications associated with their use. Tramadol, a mild opioid agonist and norepinephrine and serotonin reuptake inhibitor, is recommended by current guidelines for the treatment of moderate to moderately severe pain in patients who have not responded to previous oral therapy, or in patients who have contraindications to COX-2 inhibitors and nonselective NSAIDs. An extended-release (ER) formulation of tramadol was approved by the US Food and Drug Administration in September 2005. In contrast with immediate-release (IR) tramadol, this ER formulation allows once-daily dosing, providing around-the-clock analgesia. In clinical studies, tramadol ER has demonstrated a lower incidence of adverse events than that reported for IR tramadol. Unlike nonselective NSAIDs and COX-2 inhibitors, tramadol ER is not associated with gastrointestinal, renal, or cardiovascular complications. Although tramadol is an opioid agonist, significant abuse has not been demonstrated after long-term therapy. It is concluded that tramadol ER has an efficacy and safety profile that warrants its early use for the management of chronic pain, either alone or in conjunction with nonselective NSAIDs and COX-2 inhibitors.

Pain as a mediator of sleep problems in arthritis and other chronic conditions

OBJECTIVE

To examine the associations between arthritis and insomnia symptoms and unrefreshing sleep, as well as the role of pain as a mediator of these relationships.

METHODS

Analyses were conducted on the cross-sectional, nationally representative, weighted sample of adults > or =18 years of age (n = 118,336) in the 2000/2001 Canadian Community Health Survey. Four logistic regression models were estimated for each sleep problem (model 1: arthritis only; model 2: model 1 + sociodemographic characteristics, lifestyle factors, and other chronic conditions; model 3: model 2 + mental health [stress, depression]; and model 4: model 3 + pain). Mediation by pain was quantified by the percentage change in the effect of arthritis on a particular sleep problem by comparing models 3 and 4.

RESULTS

The prevalence of insomnia symptoms and unrefreshing sleep in persons with arthritis was 24.8% and 11.9%, respectively. These estimates are twice as high as those for persons without arthritis. In multivariate regression analyses, the addition of pain decreased the effect of arthritis by 53% (insomnia symptoms) and 64% (unrefreshing sleep). The effect of arthritis was still statistically significant in these models, suggesting that pain is a partial mediator of these relationships.

CONCLUSION

Insomnia symptoms and unrefreshing sleep affect a considerable proportion of individuals with arthritis. Pain mediates a substantial amount of the relationship between arthritis and sleep problems. Better pain management could significantly improve sleep in individuals with arthritis.

Efficacy and safety of extended-release, once-daily tramadol in chronic pain: a randomized 12-week clinical trial in osteoarthritis of the knee

The efficacy and safety of a once-daily extended-release formulation of tramadol hydrochloride (tramadol ER) was evaluated in patients with moderate to severe chronic pain of osteoarthritis (OA). This was a randomized, double-blind, placebo-controlled, parallel-group, 12-week study. Eligible patients with radiographically confirmed OA of the knee meeting the American College of Rheumatology diagnostic criteria, defined by knee pain and presence of osteophytes, plus at least age >50 years, morning stiffness <30 minutes in duration, and/or crepitus, entered a 2-7 day washout period during which all analgesics were discontinued. When pain at the index knee joint reached > or =40 mm (0-100 mm VAS), patients were randomized to tramadol ER or placebo. Tramadol ER was initiated at 100 mg QD and increased to 200 mg QD by the end of 1 week of treatment. After the first week, further increases to tramadol ER 300 mg or 400 mg QD were allowed. Outcome measures included Arthritis Pain Intensity Visual Analogue Scale (VAS), Western Ontario and McMaster Universities Arthritis Scale (WOMAC) Pain, Stiffness, Physical Function VAS subscales, Patient and Physician Global Assessment of Therapy, Sleep, dropouts due to insufficient therapeutic effect, and adverse events. Two hundred forty-six patients were randomized (tramadol ER 124, placebo 122). There were no baseline differences between the two treatments. The mean age was 61 years, mean duration of OA 12.9 years, and the mean tramadol ER dose was 276 mg QD. All efficacy outcome measures favored tramadol ER over placebo. On the primary outcome variable of average change from baseline in Arthritis Pain Intensity VAS over 12 weeks, tramadol ER was superior to placebo (least squares mean change from baseline: 30.4 mm vs. 17.7 mm, P < 0.001). Significant differences from placebo were evident at week 1, the first post-treatment visit. Similarly, outcomes on the WOMAC Pain, Stiffness and Physical Function subscales, the WOMAC Composite Scale, dropouts due to insufficient therapeutic effect, Patient and Physician Global Assessment of Therapy, and Sleep were all significantly better with tramadol ER than placebo (P < 0.001 to < 0.05). Treatment with tramadol ER results in statistically significant and clinically important and sustained improvements in pain, stiffness, physical function, global status, and sleep in patients with chronic pain. A once-a-day formulation of tramadol has the potential to provide patients increased control over the management of their pain, fewer interruptions in sleep and improved compliance.

Sleep disturbance and nonmalignant chronic pain: a comprehensive review of the literature

Sleep disturbance is an important clinical complaint for individuals with nonmalignant pain conditions. This review is a broad introduction to the literature on sleep disturbance and chronic pain conditions. The article critically reviews studies of sleep disturbance in musculoskeletal pain, arthritis, headache, and fibromyalgia. Current neurobiological hypotheses regarding the pathogenesis of sleep disturbance and chronic pain, common comorbid disorders, and pharmacologic and non-pharmacologic treatments for sleep disturbance are reviewed.

Sleep disturbances among methadone maintained patients

We examined the relationship of sleep disturbance and demographic, mental health, drug use and other factors among 225 methadone-maintained individuals. The cohort was 78% Caucasian and 54% male with a mean age of 41 years. Sleep disturbance was measured using the Pittsburgh Sleep Quality Index (PSQI) with a score >5 indicating poor global sleep quality. Eighty-four percent of subjects had PSQI scores of six or higher. In multivariate analysis, depressive symptoms, anxiety symptoms, greater nicotine dependence, bodily pain, and unemployment were associated with poorer global sleep quality (p <.01). Targeting modifiable psychological and medical risk factors that are most strongly associated with sleep disturbance may improve quality of life in drug treatment.

Improved sleep may reduce arthritis pain

Studies indicate that pain interferes with sleep and, in turn, sleep disturbances increase pain. Statistics show that up to 60% of those with arthritis experience pain during the night. But despite these findings, sleep is not generally addressed as a major treatment concern among this population. This article reviews the relationship between pain and sleep; sleep issues as they relate to 3 common types of arthritis--osteoarthritis, rheumatoid arthritis, and fibromyalgia; and holistic approaches that may be used by the patient in the self-management of pain and sleep.

Sleep and pain

Noxious stimuli and painful disorders interfere with sleep, but disturbances in sleep also contribute to the experience of pain.Chronic paroxysmal hemicrania and possibly cluster headaches are related to REM sleep. Whereas headache is associated with snoring and sleep apnea, morning headaches are not specific for any primary sleep disorder. Nevertheless, the management of the sleep disorder ameliorates both morning headache and migraine.Noxious stimuli administered into muscles during slow-wave sleep (SWS) result in decreases in delta and sigma but an increase in alpha and beta EEG frequencies during sleep. Noise stimuli that disrupt SWS result in unrefreshing sleep, diffuse musculoskeletal pain, tenderness, and fatigue in normal healthy subjects. Such symptoms accompany alpha EEG sleep patterns that often occur in patients with fibromyalgia. The alpha EEG patterns include phasic and tonic alpha EEG sleep as well as periodic K alpha EEG sleep or frequent periodic cyclical alternating pattern. Moreover, alpha EEG sleep, as well as sleep-related breathing disorder and periodic limb movement disorder, occur in some patients with fibromyalgia, rheumatoid arthritis and osteoarthritis. Depression and not alpha EEG sleep are features of somatoform pain disorder. Disturbances in sleep, pain behaviour and psychological distress influence return to work in workers who have suffered a soft tissue injury, e.g. low back pain. Patients with irritable bowel disorder have disturbed sleep and have increased REM sleep. In conclusion, there is a reciprocal relationship between sleep quality and pain. The recognition of disturbed or unrefreshing sleep influences the management of painful medical disorders.

Alpha sleep characteristics in fibromyalgia

OBJECTIVE

To characterize the patterns of alpha electroencephalographic sleep and their associations with pain and sleep in patients with fibromyalgia.

METHODS

Pain and sleep symptoms of 40 female patients with fibromyalgia and 43 healthy control subjects were studied before and after overnight polysomnography. Blinded analyses of alpha activity in non-rapid eye movement (non-REM) sleep were performed using time domain, frequency domain, and visual analysis techniques.

RESULTS

Three distinct patterns of alpha sleep activity were detected in fibromyalgia: phasic alpha (simultaneous with delta activity) in 50% of patients, tonic alpha (continuous throughout non-REM sleep) in 20% of patients, and low alpha activity in the remaining 30% of patients. Low alpha activity was exhibited by 83.7% of control subjects (P < 0.01). All fibromyalgia patients who displayed phasic alpha sleep, activity reported worsening of pain after sleep, compared with 58.3% of patients with low alpha activity (P < 0.01) and 25.0% of patients with tonic alpha activity (P < 0.01). Postsleep increase in the number of tender points occurred in 90.0% of patients with phasic alpha activity, 41.7% of patients with low alpha activity, and 25.0% of patients with tonic alpha activity (P < 0.01). Self ratings of poor sleep were reported by all patients with phasic alpha activity, 58.3% of patients with low alpha activity (P < 0.01), and 12.5% of patients with tonic alpha activity (P < 0.01). Patients with phasic alpha activity reported longer duration of pain than patients in other subgroups (P < 0.01). Additionally, patients with phasic alpha sleep activity exhibited less total sleep time than patients in other subgroups (P < 0.05), as well as lower sleep efficiency (P < 0.05) and less slow wave sleep (P < 0.05) than patients with a tonic alpha sleep pattern.

CONCLUSION

Alpha intrusion during sleep can be of different patterns. Phasic alpha sleep activity was the pattern that correlated better with clinical manifestations of fibromyalgia.

Factors related to sleep disturbance in older adults experiencing knee pain or knee pain with radiographic evidence of knee osteoarthritis

OBJECTIVES

To describe the types and frequencies of sleep complaints and the biopsychosocial factors associated with sleep disturbance in a large community sample of older adults experiencing knee pain or knee pain with radiographic evidence of knee osteoarthritis (OA).

DESIGN

Baseline analyses of an observational prospective study.

SETTING AND PARTICIPANTS

Participants were 429 men and women aged 65 years and older experiencing knee pain or knee pain with radiographic evidence of OA enrolled in the Observational Arthritis Study in Seniors (OASIS).

MEASUREMENTS

Demographic variables (age, gender, ethnicity, education), health (X-rays of knee rated for OA severity, medical conditions, medication use, smoking status, body mass index, self-rated health), physical functioning (self-rated physical functioning, physical performance), knee pain, and psychosocial functioning (social support, depression) were measured.

RESULTS

Problems with sleep onset, sleep maintenance, and early morning awakenings occurred at least weekly among 31%, 81%, and 51% of participants, respectively. Bivariate correlates of greater sleep disturbance in those with OA were less education, cardiovascular disease, more arthritic joints, poorer self-rated health, poorer physical functioning, poorer physical performance, knee pain, depression, and less social support. In regression analyses, each set of variables representing the domains of health, physical functioning, pain, and psychosocial functioning contributed to the prediction of sleep disturbance beyond the demographic set. Finally, in a simultaneous model, white race (trend, P = .06), poorer self-rated health, poorer physical functioning, and depressive symptoms were predictive of sleep disturbance.

CONCLUSIONS

Sleep disturbance is common in older adults experiencing knee pain or knee pain with radiographic evidence of OA and is best understood through the consideration of demographic, physical health, physical functioning, pain, and psychosocial variables. Interventions that take into account the multidetermined nature of sleep disturbance in knee pain or knee OA are most likely to be successful.

Nighttime sleep and daytime functioning (sleepiness and fatigue) in well-defined chronic rheumatic diseases

Wake/sleep complaints are very common in the rheumatic diseases, and include: insomnia, non-restorative sleep, frequent awakenings, daytime fatigue and excessive daytime sleepiness. Imprecise use of terminology has confused 'sleep dissatisfaction' (i.e. 'non-restorative sleep') with specific sleep disorders (i.e. 'insomnia' or 'sleep fragmentation') and 'fatigue' with 'daytime sleepiness'. This review examines current concepts from the literature of disparate disciplines pertaining to the complaint of poor sleep and daytime fatigue in patients with rheumatic disorders. The ability to monitor multiple physiologic parameters during sleep (polysomnography) has led to a greater understanding of normal and abnormal phenomena which occur during sleep, and has resulted in the identification of a variety of sleep disorders which have specific therapeutic implications. Actigraphy allows the prolonged monitoring of wake/sleep patterns, and the multiple sleep latency test permits the determination of physiologic sleepiness during the daytime. These techniques enable identification of objective sleep disorders in those whose complaint is subjective sleep dissatisfaction, and permit differentiation between the easily confused complaints of excessive daytime sleepiness and fatigue. The abnormal sleep/wake symptoms in patients with rheumatic diseases may not simply be a 'non-specific' or systemic effect of the disease. Some patients may have a specific sleep disorder (either independent from, or due to, the underlying rheumatic condition) which should be diagnosed and treated specifically. Conversely, subjective 'sleep dissatisfaction' does not necessarily imply an underlying sleep disorder. The primary intent of this review is to encourage systematic, objective study of sleep and daytime function in these common, often disabling conditions.

Associations of symptoms of sleep apnea with cardiovascular disease, cognitive impairment, and mortality among older Japanese-American men

OBJECTIVES

To examine the association between symptoms of sleep apnea and prevalent cardiovascular disease, cognitive impairment, and subsequent 3-year mortality.

DESIGN

A longitudinal study.

SETTING

Participants lived in the community on Oahu, Hawaii.

PARTICIPANTS

A total of 2905 older Japanese-American men participating in the fourth examination of the Honolulu Heart Program cohort study from 1991-1993, which is the baseline for the Honolulu-Asia Aging Study of dementia.

MEASUREMENTS

Self-reported snoring, daytime sleepiness, and breathing pauses; diagnosed cardiovascular disease and dementia; cognitive functioning and vital status approximately 3 years later.

RESULTS

More than 12% of the participants reported that they often or always snored loudly, and 8% reported being sleepy most of the day. Fewer than 2% reported that they stop breathing when sleeping, and this was found more frequently among habitual snorers (7%, P < .001) and those sleepy during the day (5%, P < .001). The prevalence of habitual snoring declined in the older age groups, was higher among those with greater Body Mass Index scores, and was not associated with the reporting of daytime sleepiness, diagnosis of heart disease, stroke, dementia, or cognitive impairment. Daytime sleepiness was more prevalent at older ages and was associated with a higher prevalence of heart disease and with cognitive impairment and dementia, chronic obstructive pulmonary disease, and diabetes. Self-reported apnea was associated only with a history of pneumonia. Three-year mortality was not associated with these symptoms after adjusting for prevalent heart disease and cognitive impairment.

CONCLUSION

Symptoms of sleep apnea are reported less frequently in older Japanese-American men. Excessive daytime sleepiness is associated with poor cognition and dementia, but whether it also is an indicator for sleep apnea in this age group remains unclear. Epidemiologic studies of sleep apnea in older adults will require polysomnography to determine accurately the correlates and consequences of this condition.

Gender, self-reported depressive symptoms, and sleep disturbance among older community-dwelling persons. FICSIT group. Frailty and Injuries: Cooperative Studies of Intervention Techniques

The purposes of this report are: (1) to investigate the association between sleep disturbances and depressive symptomatology in older adults; (2) to evaluate the degree to which gender serves to mediate this relationship; and (3) to determine whether several predefined covariates help to explain the association between sleep disturbance and depressive symptoms. This is a retrospective and cross-sectional analysis of baseline data from 485 elderly adults enrolled in three of the eight clinical sites participating in the Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) trials. FICSIT was a linked series of randomized clinical trials which evaluated the impact of various exercise interventions on several measures of frailty in older adults. Women reported more depressive symptoms and more sleep disturbances than men. Sleep disturbances were independently associated with depressive symptoms, bodily pain, a history of falling, limited education, being married, and being female. Gender interactions suggest that, although women reported more depressive symptoms and more chronic health conditions than men, both may be more important predictors of sleep disturbance in men. By contrast, being married may be more predictive in women. Finally, the data suggest a stronger relationship between sleep disturbance and depressive symptoms in men than in women.

Sleep disturbance, psychosocial correlates, and cardiovascular disease in 5201 older adults: the Cardiovascular Health Study

OBJECTIVES

To describe the prevalence of self reported sleep disturbances in older men and women and to describe their relationships with health status and cardiovascular disease (CVD).

DESIGN

Cross-sectional study of sleep disturbance, CVD, general health, psychosocial factors, physical function, and use of psychotropic medications.

SETTING

Participants of the Cardiovascular Health Study, 5201 adults aged 65 and older recruited from a random sample of noninstitutionalized Medicare enrollees in four US communities.

MEASURES

Self-reported sleep disturbances and standardized questionnaires for cardiopulmonary symptoms and diseases, depression, social support, activities of daily living, physical activity, cognitive function, and current medications, spirometry, ECG, echocardiography, and carotid ultrasound.

RESULTS

Women were twice as likely as men to report difficulty falling asleep (30% vs 14%). Daytime sleepiness, difficulty falling asleep, and frequent awakenings increased in prevalence with age. All symptoms were related strongly to depression. Symptoms of daytime sleepiness were also related strongly to poor health and limitations in activities of daily living in men and women. In multivariate analysis, men taking benzodiazepines were likely to report difficulty falling asleep and daytime sleepiness, whereas women taking benzodiazepines reported difficulty falling asleep and waking up too early. After accounting for these factors, the only cardiovascular disease independently associated with sleep disturbances was angina. Men and women with confirmed angina were 1.6 times more likely to report trouble falling asleep. Independent relationships between sleep disturbances and cardiovascular risk factors such as obesity, hypertension, smoking, and diabetes were relatively weak and inconsistent, though smokers were less likely to report frequent awakenings.

CONCLUSIONS

Sleep disturbances are relatively common in older men and women and are associated with poor health, depression, angina, limitations in activities of daily living, and the use of benzodiazepines.